Despite the catastrophic launch of the Healthcare.gov web site last fall, the Affordable Care Act (ACA) is on pace to blow past the CBO's most recent forecast of 6 million private insurance subscribers by the March 31 enrollment deadline. All told, at least 13 million people will obtain insurance coverage as a result of Obamacare, including 3 million young adults under age 26 added to their parents' (a majority of them Republican) policies. As with President Bush's Medicare Part prescription drug plan 8 years ago, ACA approval is climbing. The markets, too, have spoken, with stock prices for major insurers surging as their CEOs signal their pleasure with the total number and age mix of their new customers.
But given the unprecedented four-year Republican war to smother it in its cradle, Obamacare's recovery is all the more remarkable. A seemingly unending torrent of court challenges by state Republicans and right-wing front groups has held up ACA implementation in many states. (If they succeed in Halbig v. Sebelius, they will effectively undo the Affordable Care Act in 34 states altogether.) A misinformation campaign about make-believe deficits, mythical "death panels," a pretend "government takeover of health care" and a supposedly simultaneous insurance industry "death spiral" and "bailout" left Americans--especially the uninsured--fearful, confused and shockingly ill-informed.
Yet as damaging as that uncertainty and chaos has been, the Republican Party's scorched-earth opposition to Obamacare is producing something far worse: a body count. That's not hyperbole, but a grim reality. Due to what might be the greatest act of political spite in modern American history, Republicans will needlessly leave millions of people uninsured, many hospitals on the edge of financial ruin and thousands of Americans dead, mostly in the states the GOP itself controls.

Here's how the Republicans' killer math works.
Prior to the full implementation of the Affordable Care Act, studies from the Urban Institute, Families USA and Harvard Medical School estimated the numbers of preventable deaths among America's 50 million uninsured at between 22,000 and 45,000 a year. But as 25 plus million Americans gain coverage over the next decade (according to the nonpartisan CBO), that unnecessary death toll would drop dramatically. Just not, it turns out, in the GOP-dominated states that refused to accept the Affordable Care Act's expansion of Medicaid to millions of their currently uninsured constituents.
That's the conclusion a team of researchers from Harvard Medical School recently published in Health Affairs. The authors of "Opting Out Of Medicaid Expansion: The Health And Financial Impacts" tallied up the coming body count in the Republican states that rejected the ACA's extension of Medicaid to millions of their residents:

Nationwide, 47,950,687 people were uninsured in 2012; the number of uninsured is expected to decrease by about 16 million after implementation of the ACA, leaving 32,202,633 uninsured. Nearly 8 million of these remaining uninsured would have gotten coverage had their state opted in. States opting in to Medicaid expansion will experience a decrease of 48.9 percent in their uninsured population versus an 18.1 percent decrease in opt-out states...
We estimate the number of deaths attributable to the lack of Medicaid expansion in opt-out states at between 7,115 and 17,104. Medicaid expansion in opt-out states would have resulted in 712,037 fewer persons screening positive for depression and 240,700 fewer individuals suffering catastrophic medical expenditures. Medicaid expansion in these states would have resulted in 422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64. Expansion would have resulted in an additional 658,888 women in need of mammograms gaining insurance, as well as 3.1 million women who should receive regular pap smears.

To put those findings in terms Republicans can understand, up to 3,000 of Rick Perry's Texans will needlessly die each year. Those dead will joined by up to 671 from Scott Walker's Wisconsin, 1,176 in Nathan Deal's Georgia, 2,221 in Rick Scott's Florida and 1,145 in Pat McGrory's North Carolina. It's no wonder Ohio GOP Gov. John Kasich got biblical on Buckeye State Republicans to extend Medicaid coverage to 300,000 of their state's residents:

"When you die and get to the meeting with St. Peter, he's probably not going to ask you much about what you did about keeping government small, but he's going to ask you what you did for the poor. You'd better have a good answer."

The impact, if not the death toll, of red state rejectionism even got the attention of the reliably Republican Wall Street Journal. Six months after outlets like McClatchy warned of the looming "coverage gap," the Journal reported:

For now, nearly five million people ages 18 to 64 get no financial help to buy coverage because of the gap, according to estimates by the Kaiser Family Foundation. Many of those people are clustered in the South, living in states where income limits for Medicaid coverage have historically been among the lowest in the U.S.

Which is exactly right. Under the Affordable Care Act, the federal government provides subsidies for individuals and families earning between 138 percent and 400 percent of the Federal Poverty Level (FPL) to purchase private health insurance. Below that level, Uncle Sam pays for Medicaid coverage. Unless you happen to live in one of the 24 GOP-controlled states which said no to the Medicaid expansion.

In those states, generally the very ones where health care is the worst, the current reach of Medicaid is shocking. As the Journal noted, Alabama's Medicaid program has an income ceiling of $2,832 for a family of two, after deductions. As the Washington Post's Glenn Kessler explained three years ago:

Mississippi provides some of the lowest Medicaid benefits to working adults in the nation. A parent who isn't working can qualify only if annual family income is less than 24 percent of the poverty line. Working parents qualify only if they make no more than 44 percent of the federal poverty level. Seniors and people with disabilities are eligible with income at 80 percent of the poverty line...
Translated from the federal poverty guidelines, that means a working Mississippi couple with one child could earn no more than $8,150 a year and still qualify for Medicaid, seniors and people with disabilities could earn no more than $8,700, and a pregnant woman could earn no more than $20,000 a year.

It's no wonder McClatchy described the coverage gap as "a bureaucratic twilight zone where people with poverty-level incomes don't qualify for Medicaid and can't get tax credits to help buy coverage on the new insurance marketplaces."
To call the Medicaid-denying states "bureaucratic twilight zones" is being kind. In a very real sense, their leaders are true death panelists, condemning thousands of their constituents annually by refusing to accept billions of dollars from Washington that are virtually free.
Really.
The federal government will pay for 100 percent of the cost of the Medicaid expansion until 2017 and 90 percent after that. Each state is then on the hook for the other 10 percent. The loss to rejectionist red state coffers, the Commonwealth Fund found, is staggering. As USA Today summed it up:

By 2022, Texas could lose $9.2 billion by not expanding Medicaid as allowed under the Affordable Care Act, while Florida could lose $5 billion over that period, the study conducted by The Commonwealth Fund shows...Also during that period, the study showed, Georgia could lose $2.9 billion, while Virginia could lose $2.8 billion.
"There are no states where the taxpayers would actually gain by not expanding Medicaid," said Sherry Glied, lead author on the study. "Nobody wins."

Nobody wins, analyses show, because the Republican Medicaid deniers are being penny wise and pound foolish. The billions the "opt-out" states saved by not expanding Medicaid in future years will be more than offset by their extra costs to compensate hospitals and other providers for the care of the uninsured. As Ezra Klein and Evan Soltas summed up an analysis by the RAND Corporation of 14 Medicaid rejecting states last year:

It finds that the result will be they get $8.4 billion less in federal funding, have to spend an extra $1 billion in uncompensated care, and end up with about 3.6 million fewer insured residents.
So then, the math works out like this: States rejecting the expansion will spend much more, get much, much less, and leave millions of their residents uninsured. That's a lot of self-inflicted pain to make a political point.

A lot of pain, indeed, especially in Georgia. There, Gov. Deal said no to $33 billion in new federal Medicaid funding over the next decade. But as the federal government significantly reduces funding on Disproportionate Share Hospital (DSH) payments for the care of the uninsured, states like Georgia which turned down Obamacare's Medicaid dollars will be on the hook to make up the difference. For Grady Memorial Hospital, the largest in the metro Atlanta area, what could have been an annual boon of $60 million and coverage for 27,000 uninsured patients instead will be a $45 million loss. In February, a fourth rural hospital announced it was shutting its doors due to a lack of patients who can pay for their medical expenses. As the New York Times reported in November, Memorial Hospital in Savannah, Georgia, "is now facing the loss of nearly half of its roughly $100 million in annual subsidies known as disproportionate share hospital payments."

The Times explained how the Republican temper tantrum after the Supreme Court made Medicaid expansion optional for the states is putting red state hospitals at risk:

Now, in a perverse twist, many of the poor people who rely on safety-net hospitals like Memorial will be doubly unlucky. A government subsidy, little known outside health policy circles but critical to the hospitals' survival, is being sharply reduced under the new health law.
The subsidy, which for years has helped defray the cost of uncompensated and undercompensated care, was cut substantially on the assumption that the hospitals would replace much of the lost income with payments for patients newly covered by Medicaid or private insurance. But now the hospitals in states like Georgia will get neither the new Medicaid patients nor most of the old subsidies, which many say are crucial to the mission of care for the poor.

Which is just one of the reasons why an increasing number of red state governors are accepting the dollars from DC. GOP governors in Michigan, Pennsylvania and Ohio ran the numbers. In Ohio, Gov. John Kasich's decision to take Washington's money will actually produce a $400 million surplus for the Buckeye State (one which Republican legislators want to give away in the form of more tax cuts). The simple math-and simpler consideration in insuring millions of indigent patients as the DSH funding is reduced over time is precisely why hospital associations in Texas, Kentucky, Mississippi, North Carolina and every other state pleaded with Republican governors and legislatures to take Obamacare's money for Medicaid expansion. In October, the Fitch ratings agency released a special report titled, "Adverse Expansion: Hospitals, States and Medicaid," which warned that:

"Hospitals operating in states not expanding Medicaid, which usually have higher uninsured and poverty rates, will have to absorb the full impact of the ACA reimbursement cuts without the full benefit of increased insured volumes," said Adam Kates, Director in Fitch's Public Finance group. Texas, Florida, Georgia, Louisiana, Mississippi, and South Carolina are not expanding Medicaid and have among the highest uninsured and poverty rates, and some of the most stringent Medicaid eligibility requirements. Fitch believes hospitals in these states, particularly those with weak payer mixes, will be particularly vulnerable.

It's no wonder Arizona Gov. Jan Brewer, certainly no friend of Barack Obama, explained her decision to extend Medicaid coverage to 300,000 more people in her state this way:

"It's pro-life, it's saving lives, it is creating jobs, it is saving hospitals."

Just not in the states where Republicans said no.
The GOP's poisonous opposition to the Affordable Care Act is proving toxic to red state residents in myriad other ways as well. Despite the fact that Medicare has used a virtually identical outreach program for over 20 years, Missouri, Texas and seven other GOP-dominated states have erected draconian barriers to the work of so-called Obamacare "navigators." The network of community groups, non-profit organizations, hospitals and universities receiving funds to assist and enroll new insurance subscribers are being blocked from doing so. As the Texas Tribune reported, the result is that "only 12 percent of Texans who are estimated to be eligible for subsidies have actually enrolled," leavings tens of millions of dollars in federal subsidies on the table. In Florida, by contrast, the Democratic Party's extensive infrastructure and outreach to nonprofits has helped overcome the intransigence of the Republican-controlled governor's mansion and legislature:

More than 440,000 Florida residents had been enrolled through the federal marketplace through the end of February, putting Florida on pace to exceed the federal government's initial projections by the time enrollment closes March 31.
The numbers are impressive for a state where Republicans control the governor's mansion and both houses of the Legislature. By comparison, Republican-leaning Texas has enrolled 295,000 through the federal site, even though its population is about a third larger than Florida's.

The conservative skullduggery doesn't end there. Several Representatives, like Jason Chaffetz (R-UT) and Tim Huelskamp (R-KS), announced they would not answer constituent calls about the Affordable Care Act. In August, Texas joined Arizona, Alabama, Missouri, Oklahoma and Wyoming in refusing to guarantee that insurance companies follow the ACA's new regulations. Residents of those states encountering abuses by insurers will have to contact the feds instead.
Now, the roll-out of Obamacare hasn't been derailed in every red state. Idaho and North Carolina have blown past the projections for private insurance purchases. In Kentucky, a state that supported Mitt Romney over Barack Obama by a two-to-one margin, Democratic Gov. Steve Beshear has led a model implementation of the state's health care exchange and Medicaid expansion.
During the 2012 presidential campaign, Republican National Committee Chairman Reince Priebus made a startling statement. The president, Priebus charged, "stole $700 billion from Medicare to fund Obamacare," adding, "If any person in this entire debate has blood on their hands in regard to Medicare, it's Barack Obama." That was a pretty remarkable claim for the RNC chief to make. After all, 95 percent of Republicans in Congress have voted three years in a row for the Paul Ryan House GOP budget that uses the exact same $700 billion in savings from Medicare providers to help fund a massive tax cut windfall for the wealthy. (That farce was repeated last fall, when the Republicans who shut down the government over their aborted effort to "defund Obamacare" nevertheless wanted to keep very dollar in revenue the Affordable Care Act raised or saved.)
But Priebus' slander was absurd for a more basic reason. Thanks to his Republican Party and its all-out war on the Affordable Care Act, up to 17,000 Americans will needlessly die each year. Not because Republicans fear Obamacare will fail, but because they fear it will succeed. With the Affordable Care Act now the law of the land, the GOP's red state death toll can't be attributed to philosophical or budgetary objections, but instead just to sheer spite.
(This piece first appeared at Dailykos.)